Cost-effectiveness of primary implanted cardioverter defibrillator for sudden death prevention in congestive heart failure.

BACKGROUND: Implanted cardioverter defibrillator (ICD) is expensive but highly effective in preventing sudden death. The value of primary prophylactic ICD in preventing sudden death for congestive heart failure patients (CHF) has not been established.
OBJECTIVE: To compare the cost-effectiveness of primary prophylactic ICD vs. standard drug therapy for preventing CHF sudden death.
DESIGN: Incremental Cost per Quality-Adjusted Life Year (QALY) using a lifetime decision model. DATA SOURCES: Estimates of cost, utility and probabilities from literature, clinical experts, CMS fee schedule payments, and the Bureau of Labor Statistics. TARGET POPULATION: U.S. CHF patients with NYHA functional Class II and III. TIME HORIZON: Lifetime; future values discounted at 3%. PERSPECTIVE: Societal. RESULTS OF BASE-CASE ANALYSIS: In 2002 prices the discounted lifetime cost is 122,947 dollars with primary prophylactic ICD and 25,223 dollars without ICD; the QALYs gained were 2.9031 and 1.9045 respectively. The incremental cost-effectiveness ratio was 97,861 dollars per QALY saved with prophylactic ICD. RESULTS OF SENSITIVITY ANALYSIS: ICD is not cost-effective under plausible scenarios using 50,000-80,000 dollars per QALY as the cost effectiveness threshold. The cost-effectiveness ratio is quite sensitive to patient utility after ICD implantation, and the proportion of CHF patients experiencing sudden death.
CONCLUSIONS: Using a standard cost-effectiveness threshold and plausible parameter ranges, it is unlikely that ICD is cost-effectiveness in preventing CHF sudden death relative to standard drug therapy.